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SAN aJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM It Facility Name: s ��J�'�� Page of Facility Address: / T - S City: �� Inspectio Date:. z 3/0 G J o FA #: U � PR #: ©��D Pro ram Element: z > 19 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks* and containers**. Complete one box for each tank or each cumulative container product type. �� m Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: S h gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) Containers (2821) #of Containers: TA#:/, 2 Total Capacity: 2 0 p y: � gallons Product Type: /I� v 7T�'� X71 (per tank or cumulative for containers by product type) Install Date: I ank (2820) Containers (2821) #of Containers: % TA#: 3 Total Capacity: Z p y: gallons Product Type: �[�%}r/%� 6/'� O`iii (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: Tank (2820) ❑ Containers (2821) 4 Total Capacity: �? (} p y: gallons Product Type: %i/% Sri 0 (per tank or cumulative for con ainers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: n gallons Total Capacity for Site: gallons Comments: EHD Inspector: (—V` A Reviewed Date: By Initial: Entered Date: By Initial: / D Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08/08